Appealing Medical Claims
Patients can utilize their medical insurance to pay for some procedures at the dental clinic. Medical insurance may provide more coverage than dental insurance. Albeit, medical insurance companies may deny claims for a variety of reasons. In response, dentists and patients could appeal the claims.
Patients can go through different processes to overturn the denial. Patients can go through an internal appeal process, where the insurance company “[conducts] a full and fair review of its decision. If the case is urgent, [their] insurance company must speed up this process” (“How to appeal an insurance company decision”). Alternatively, they could go through an external review process handled by an independent third party and “the insurance company no longer gets the final say over whether to pay a claim” (“How to appeal an insurance company decision”). Patients with an employer’s health insurance policy or an individual health plan can appeal the claim through their state’s appeals process, whose rules may vary from state to state (“How to Appeal a Health Insurance Denial”). Those on Medicare must go through a federal appeals-review process (“How to Appeal a Health Insurance Denial”).
To avoid denials, dentist practice staff members should remain updated on the diagnostic ICD and procedure CPT codes and their rules and regulations every year (Varga 2013). When insurance companies deny claims, dentists and patients can succeed in appealing the claim in a variety of ways, depending on the situation. Dentists should help patients appeal these claims in order to approve their coverage, allowing patients to financially access any necessary procedures (Varga 2013).